Physiological

Adaptation
Archer Review

© USMLE Galaxy LLC

Physiological Adaptation
(RN 11 - 17%)
(PN 7 - 13%)

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Key Topics
▪ Invasive procedures
▪ Arterial line
▪ Ventilation management
▪ Pulmonary hygiene
▪ Ostomy and wound care
▪ Dialysis care
▪ Phototherapy (RN)
▪ Pacemaker management
▪ Hemodynamics

▪ Education/Patho on acute and chronic diseases →Watch adult health subject videos
▪ Telemetry → Watch EKG interpretation
▪ Fluid and electrolytes → Watch fluid and electrolyte videos (3)

Invasive Procedures

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Central Venous Catheter (CVC)
● Types
○ IJ
○ PICC
○ Hickmann
○ Broviac
○ TT

Central Line
Uses:

● Transfusing fluids that are irritating to the vascular system

○ Hypertonic solutions, TPN, rapid blood administration
○ Preferred: potassium and vancomycin
● Central Venous Pressure monitoring

Insertion/Removal

● Reduce risk of air emboli

○ Trendelenburg client
○ Have client perform valsalva maneuver
● Infection risk
○ Placement and dressing changes must be STERILE
○ Change IV tubing every 96 hours (or per facility protocol)

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 Arterial Line
Purpose

● Gives continuous and accurate blood pressure

readings
● Allows for quick access to gather a blood specimen

Placement

● In an artery
○ Radial, brachial, axillary, or femoral
● Sterile technique must be used

Calibration

● Ensure transducer is level with the right atrium

● Ensure system is zeroed for an accurate reading

Thoracentesis
● Removes fluid/air from the pleural space
● Positioning
○ Leaning over a bedside table
○ Semi-fowlers unaffected side down
● Procedure
○ Local anesthetic will be applied - may cause a stinging feeling
○ Have client hold breath when provider is inserting the needle
○ No more than 1,000 mL should be removed
■ If more fluid needs to be removed, a chest tube will be inserted
● Risks
○ Pneumothorax
■ Pain during inspiration, tachycardia, absent breath sounds on one side
○ Mediastinal shift
■ Chest pain/anxiety
○ Infection
■ Fever/ increase in WBC

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Bronchoscopy
● Used to look at the airway structures or obtain a tissue sample
● Types
○ Rigid Bronchoscopy - general anesthesia
○ Flexible Bronchoscopy - bedside sedation in the ICU
● Preprocedure
○ NPO 4-8 prior
○ May give benzodiazepines/opioids for light sedation
● Postprocedure
○ Ensure gag reflex intact
■ Nothing to eat or drink until gag reflex has returned
○ Monitor for bleeding/infection

Ventilator Management

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 Terminology
● Peak Inspiratory Pressure (PIP): The highest level of pressure in the lungs during
inhalation.
● Positive End Expiratory Pressure (PEEP): The amount of pressure in the alveoli at
the end of expiration.
● Fraction of inspired oxygen (FiO2): How much oxygen the patient is getting.
21-100%
● Tidal volume (TV): The amount of air that is inhaled during one respiratory cycle.
● End-Tidal Carbon Dioxide (ETCO2): The partial pressure of CO2 detected at the
end of exhalation.
● Room air: The atmospheric air we breathe under normal circumstances. It has an
FiO2 of 21%.

Ventilator Modes
Volume-controlled: There is a certain volume of air delivered to the client with each breath

Pressure-controlled: The lungs are inflated to a certain pressure

CPAP (continuous positive airway pressure): There is continuous positive airway pressure,
while the client controls their respiratory rate and volume

BiPAP (bilevel positive airway pressure): There is positive airway pressure, set at different
pressures for inspiration and expiration

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Alarms
High Pressure Alarms Low Pressure Alarms
Pressure in the circuit is too high. Pressure in the circuit is too low.

Causes: Causes:
Patient coughing Tubing is disconnected
Gagging Loose connections
Bronchospasm Leak
Fighting the ventilator Extubation
ETT occlusion Cuffed ETT or trach is deflated
Kink in the tubing Poorly fitting CPAP/BiPAP mask
Increased secretions
Thick secretions
Water in ventilator circuit

Client Care
● Every two hours
○ Assess for suctioning needs
■ Check vital signs and listen to lung sounds
○ Oral Care
■ This prevents ventilator associated pneumonia
■ Keeps oral mucosa moist
○ Passive range of motion
■ Prevents contractures
● Once every 24 hours (per hospital policy)
○ Sedation vacation
■ Turn sedation off long enough to check if client is alert and oriented
■ Doing this helps improve long term outcomes

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 Pulmonary Hygiene

Pulmonary Care
Incentive spirometer - (Inhale to make ball rise)
1. Help client sit upright
2. Have client take a deep breath in through their mouth and exhale
3. Seal lips around the mouth piece
4. Inhale through the mouth and raise the ball as high as possible
5. Hold breath for 3 - 5 seconds
6. Exhale
7. Repeat for a total of 10 breaths/hour

Chest Physiotherapy
● Uses specific client positioning and percussion with the hands cupped to help mobilize secretions and help the
client to clear their airways

*Having client turn, cough, and deep breathe every 2 hours is helpful for
preventing pulmonary complications

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 Drainage Devices

Wound Drains
● Open drainage - increased infection risk
○ Penrose drain
■ Drainage by gravity
○ T - Tube
■ Inserted temporarily into the bile duct
■ Allows bile to drain
● Closed-suction drains - decreased infection risk
○ Hemovac
■ Bellows are collapsed to place suction on the wound
■ Removes fluids/blood from wound
■ Removed once drainage slows
○ Jackson-Pratt drain
■ Bulb is compressed to to place suction on the wound
■ Removed fluids/blood from the wound
■ Removed once drainage slows

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Chest Tube
● Tube inserted into the pleural space
of the lungs
● Helps to remove air or fluid that has
caused the lung to collapse
● Also placed after cardiac surgery into
the pericardial space to help drain
blood and fluid from around the heart

Ostomies
● Types:
○ Ileostomy - redirects stool from the small intestine
■ Stools will be more liquidy and yellow in color
○ Colostomy - redirects stool from the large intestine
■ Stools will be formed and darker in color
○ Urostomy - redirects urine drainage
● Stoma
○ Pink/Red and moist (should not be purple/grey/or black - indicated necrosis)
○ Use mild soap and water to clean the area around the stoma
● Pouch
○ Wafer should be cut slightly larger than the stoma to prevent strangulation
○ Ensure proper seal and no/minimal leakage
○ Change every 3 - 7 days

*Psychosocial needs should be met: discuss body image/support groups

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 Dialysis

Types
A treatment that gets rid of the bodies unwanted toxins, waste products and
excess fluids by filtering the blood.

1. Hemodialysis
2. Peritoneal Dialysis

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Hemodialysis
● Done 3-4 times per week
● Client must be anticoagulated
● Will cause rapid fluid shift (300-800
mL/min)
○ Monitor BP
○ Monitor electrolytes
○ Not all clients can tolerate
● Client must have a fistula
○ No BPs/venipuncture in the arm of the fistula
○ Palpate a thrill
○ Auscultate a bruit
● Complications:
○ Disequilibrium syndrome
■ Nausea, vomiting, headache, and restlessness
○ Hypotension

Peritoneal Dialysis
● Uses the peritoneal membrane as the filter
instead of a machine
● Process
○ Dialysate is infused into peritoneal
cavity (2,000-2,500 mLs)
○ Dwells for about 6 hours
○ Fluid is drained, taking the toxins along
with it
● Drainage should be clear
○ Cloudy drainage indicates an infection
● Ensure all of the diastylate gets drained out
○ Turn side to side if decreased fluid
return
● This is better for clients who cannot tolerate
the fluid shifts in hemodialysis

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 Phototherapy

Phototherapy
● Helps break down bilirubin so it may
be excreted in the feces
● Must ensure the eyes and genitals are
covered
● Monitor the level and distance from
the light if overhead therapy being
used
● Double, triple, and quadruple therapy
depending on severity

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 Pacemakers

Pacemakers
DO:
● Keep a pacemaker identification card in your
wallet
● Take a bath and shower 48 hrs post PPM
insertion
● Operate household appliances - it’s safe!
● Notify airport security of pacemaker

DON’T:
● Apply pressure over the generator
● Wear tight clothing
● Get lead wires wet (temporary pacemakers)
● Get an MRI (newer machines may be safe
but it is important to always double check)

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 Hemodynamics

Hemodynamics
● Preload
○ Amount of blood returning to right side of the heart
● Afterload
○ Pressure against which the left ventricle must pump to eject blood
● Compliance
○ How easily the heart muscle expands when filled with blood
● Contractility
○ Strength of contraction of the heart muscle

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 Cardiac output
The amount of blood that the heart
pumps per minute

CO = SV x HR

WHY is CO so important!?
● Tissue perfusion!
● End organ function
● Delivery of oxygen and nutrients to each and every cell in the body!
● Poor cardiac output??
○ Decreased LOC (not enough blood flow to the BRAIN)
○ Chest pain, weak peripheral pulses (not enough blood flow to the HEART)
○ SOB, crackles, rales (not enough blood flow away from the LUNGS)
○ Cool, clammy, mottled extremities (not enough blood flow to the SKIN)
○ Decreased UOP (not enough blood flow to the KIDNEYS)

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Postoperative Care

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Post-Operative Care
1. Assessment
○ Airway, breathing, and circulation
○ Does the client have a bleeding risk?
○ Are there signs of infection?
○ Monitor vital signs
2. Pain Management
○ Pharmacological and non-pharmacological measures should be used
3. Wound care/Dressing changes
○ Provider will likely want to do the first dressing change after surgery
4. Mobility
○ We want to encourage early ambulation if possible
5. Respiratory Care
○ Ensure good lung health (incentive spirometer, turn, cough, and deep breathing)
6. Nutrition
○ Encourage a diet with high protein, zinc, iron, and vitamins A, B, C, E, and K
7. Client Advocacy
○ Provide client education
○ Provide emotional support
8. Discharge planning

Post-op Client
NGN Case Study

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The nurse cares for a client in the outpatient surgical center who
is scheduled for a cholecystectomy:

Nurses'
Note
0730 – Client arrives at the preoperative area with his family. He reports
that he is anxious about the procedure. Pre-operative checklist was
completed at this time. 20-gauge peripheral vascular access established in
the right antecubital space. + blood return and flushes without resistance.
The client reports no pain at the insertion site.

Preoperative
Checklist

Item Result
Demographics ● ID verified
● ID band applied
● Height and weight obtained
Legal ● The surgeon has not obtained
consent
● The client indicated he has no
advanced directives
Medications ● Client took his prescribed
phenytoin with a sip of water
this morning
● Client stopped his prescribed
warfarin five days ago

Diet ● The client reports his last meal

was the previous day at 2200
● He has not consumed any food
or water since that time

Laboratory ● CBC; CMP; PT/INR; Type and

Screen; UA specimens sent, and
results are pending
Personal belongings ● The client had no jewelry
● No dentures or partial plates

Discharge planning ● The client stated he was going

to drive himself home after the
procedure
Education ● Client was educated on
postoperative pain
management and VTE
prevention – successful return
demonstration provided

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The nurse reviews the pre-operative checklist. Which two (2) areas of the
checklist require follow-up by the nurse?
Item Result
Demographics ID verified
a. Demographics
●
● ID band applied
● Height and weight obtained
Legal ● The surgeon has not obtained consent

b. Legal ● The client indicated he has no advanced directives

Medications ● Client took his prescribed phenytoin with a sip of

c. Medications
water this morning
● Client stopped his prescribed warfarin five days
ago

d. Diet Diet ● The client reports his last meal was the previous
day at 2200
● He has not consumed any food or water since that
time
e. Discharge planning Laboratory ● CBC; CMP; PT/INR; Type and Screen; UA
specimens sent, and results are pending

f. Education
Personal belongings ● The client had no jewelry
● No dentures or partial plates

Discharge planning ● The client stated he was going to drive himself

home after the procedure

Education ● Client was educated on postoperative pain

management and VTE prevention – successful
return demonstration provided

The nurse reviews the pre-operative checklist. Which two (2) areas of the
checklist require follow-up by the nurse?

a. Demographics
b. Legal
c. Medications
d. Diet
e. Discharge planning
f. Education

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Complete the sentences below using the options
Select
incomplete informed consent
The nurse should notify the primary healthcare
provider (PHCP) about the warfarin stopped five days ago
phenytoin taken with a sip of water

Select
a knowledge deficit.
Because the client has a risk of bleeding.
aspiration.

Complete the sentences below using the options

Select:
incomplete informed consent
The nurse should notify the primary healthcare
provider (PHCP) about the warfarin stopped five days ago
phenytoin taken with a sip of water

Select:
a knowledge deficit.
Because the client has a risk of bleeding.
aspiration.

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The nurse contacts the physician regarding the incomplete
informed consent

Select
autonomy.
The nurse understands that the client consenting to the
surgical procedure is essential because it demonstrates fidelity.
veracity.

The nurse contacts the physician regarding the incomplete

informed consent

Select:
autonomy.
The nurse understands that the client consenting to the
surgical procedure is essential because it demonstrates fidelity.
veracity.

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The physician orders three medications

Physician Orders

● Lorazepam 1 mg PO x 1 dose
● Cefazolin 2 grams IVPB x 1 dose
● 0.9% saline at 70 mL/hr x 1 liter

Complete the table below and specify the appropriate nursing intervention for each
medication. Each category must have at least one (1) response option selected.

Categories Potential Nursing Interventions

Lorazepam 1 mg PO ☐ Raise side rails after administration
☐ Obtain vital signs before administration
☐ Monitor deep tendon reflexes q 30 minutes

Cefazolin 2 grams IVPB ☐ Administer 60 minutes prior to incision

☐ Assess the client for any allergies to penicillin
☐ Administer with y-type tubing

0.9% saline at 70 mL/hr ☐ Watch for signs/symptoms of hypovolemic shock

☐ Assess the patency of intravenous (IV) catheter
☐ Insert an indwelling urinary catheter

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Complete the table below and specify the appropriate nursing intervention for each
medication. Each category must have at least one (1) response option selected.

Categories Potential Nursing Interventions

Lorazepam 1 mg PO ☐ Raise side rails after administration
☐ Obtain vital signs before administration
☐ Monitor deep tendon reflexes q 30 minutes

Cefazolin 2 grams IVPB ☐ Administer 60 minutes prior to incision

☐ Assess the client for any allergies to penicillin
☐ Administer with y-type tubing

0.9% saline at 70 mL/hr ☐ Watch for signs/symptoms of hypovolemic shock

☐ Assess the patency of intravenous (IV) catheter
☐ Insert an indwelling urinary catheter

The nurse administers the prescribed lorazepam and 0.9% saline

45 minutes later, the physician asks the nurse to witness the client's informed
consent. The nurse should take which priority action when witnessing the
informed consent?

a. Ensure that the consent has no abbreviations

b. Provide the client with their glasses to review the consent
c. Notify the physician that the client just received lorazepam
d. Document the completion of the consent in the checklist

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The nurse administers the prescribed lorazepam and 0.9% saline
45 minutes later, the physician asks the nurse to witness the client's informed
consent. The nurse should take which priority action when witnessing the
informed consent?

a. Ensure that the consent has no abbreviations

b. Provide the client with their glasses to review the consent
c. Notify the physician that the client just received lorazepam
d. Document the completion of the consent in the checklist

The nurse reviews the physician's progress note

Progress Note

Surgery was rescheduled because the client was unable to give consent after
receiving lorazepam. Will allow the client to recover from the lorazepam and
discharge the client home. The plan is to reschedule the client's surgery in 24 hours.

Two hours later, the nurse prepares to discharge the client home

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Prior to discharging the client home, the nurse should perform which
actions? Select all that apply.

a. Obtain vital signs

b. Determine the client's transportation home
c. Remove the peripheral vascular access
d. Educate the client to resume their prescribed warfarin
e. Reinforce preoperative education

Prior to discharging the client home, the nurse should perform which
actions? Select all that apply.

a. Obtain vital signs

b. Determine the client's transportation home
c. Remove the peripheral vascular access
d. Educate the client to resume their prescribed warfarin
e. Reinforce preoperative education

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